The Joint Commission on Accreditation of Health Care Organizations requires the Clinical Center to have a program to evaluate equipment failures and user errors. The principal features of this program are: 1. Investigation of incidents involving equipment and patients or visitors or employees. 2. Processing of recall notices sent by equipment manufacturers, safety organizations and government agencies. 3. Formulation of a plan of action to resolve safety hazards related to equipment. 4. Participation in the resolution of the safety hazards. 5. Participation in the evaluation of effectiveness of actions taken. To accomplish the program we interview patients, medical and support staff and others involved in incidents involving clinical and nonclinical equipment. We work closely with the Safety Officer, Clinical Center and the Division of Safety to formulate and carry out corrective procedures. This often involves removal of equipment, modification of equipment by manufacturers and training of clinical staff. We also participate in the evaluation of corrective actions through our activity on hospital committees.